Interventional Pain Procedures
Epidural Steroid Injection
This is a conservative procedure to attempt to control pain due to swollen and irritated nerve roots in the back or neck. These nerve roots can become irritated from bulging disks, spinal stenosis, or arthritis.
The epidural space is the area outside of the sac that contains the spinal cord. Placing steroid in the space reduces the swelling and irritation. The steroid anti-inflammatory effect usually takes place 24 to 48 hours after the injection and reaches its maximal efficacy at seven to ten days. Some people experience only a very brief period of relief or none at all, and some people have good long term relief. In some cases a series of two or three injections two to six weeks apart may be necessary. Often, failure to bring relief indicates that there may be another source of the pain.
Your surgeon may order a “selective nerve root block” which addresses a particular nerve where it exits the spinal cord, often causing leg or arm pain. This nerve block is also in the epidural space and is performed with a slightly different technique. It is both diagnostic and therapeutic. You will have immediate relief of your usual pain if that particular nerve is responsible. The steroid effect will not take place for 24 to 48 hours, and the numbing usually wears off before relief from the steroid begins.
Facet Joint/Medical Branch Block
The facet joints are the joints in your spine where the vertebral bones are stacked upon one another. The medial branch nerves are responsible for the sensation of pain coming from the facet joints. Each joint is serviced by two medial branch nerves. The medial branch nerve block is used to determine if your pain is coming from your facet joints. If your usual back pain improves for a few hours after the procedure, it is likely that this is the source of your pain. A repeat block is also performed on another day to ensure that the proper level(s) is/are being addressed. If both blocks give pain relief, you are a candidate for a facet rhizotomy which is described below. Steroid is often deposited in or near the joint during the first procedure, and it is possible that you will have longer term relief from this. However, the diagnostic information from the effects of the numbing medicine is the most significant. You will be given a pain journal to keep track of the quality and duration of your pain relief over the next several hours after the block.
Facet Rhizotomy/Radiofrequency Ablation
If your pain has been determined to be coming from your facet joints, a medial branch nerve ablation (intentional destruction) is a non-surgical procedure that uses heat to carefully and selectively damage the nerves that carry the pain message coming from the facet joints. Relief is often experienced for six to twenty-four months. These medial branch nerves do not control any muscles or sensation in your arms or legs. There is no evidence that an inability to feel pain in these small joints in your back could cause further damage. Alleviating this pain generally allows people to become better conditioned and use better posture as well as perform activities that are otherwise painful. It is also a way to treat pain coming from the joints above or below a fusion.
The procedure is conducted just as the medial branch nerve block is though a small amount of electrical testing which is non-painful is also carried out. All nerves are thoroughly numbed prior to heating with radiofrequency. Your back may occasionally hurt more after this procedure for a few days while the nerves are dying from the heat lesion. Complete separation of the nerves takes two to three weeks at which point you will hopefully experience at least 75% relief of your usual pain until the nerves grow back in six to twenty-four months. The procedure can then be repeated at that time if the pain is the same. Repeat diagnostic blocks are often not necessary.
Sacroiliac Joint Injection
The sacroiliac (SI) joints are long joints between your sacrum (lower spine) and the bone which holds the hip joint. An SI injection can be both diagnostic and therapeutic. Placing anesthetic in the joint and evaluating your comfort level afterwards helps confirm whether or not the joint is the source of your pain. Additionally steroid placed in the joint can decrease inflammation for a longer duration and often permit physical therapy to be accomplished more effectively. Pain coming from this joint is often fairly responsive to physical therapy, especially after some of the inflammation is decreased.
For all procedures the proper level and site are identified using fluoroscopy which is essentially an instant x-ray. All procedures require that you bring a driver for after the procedure because of a small risk of temporary numbness, weakness, or effects from sedation.